The opioid crisis is better understood as a fentanyl crisis with real dangers to emergency responders, according to an expert-panel presentation convened in Las Vegas at EMS World Expo 2017.

A potentially lethal dose of fentanyl. (Photo/DEA)

The panel discussion, sponsored by Bound Tree Medical, included a Drug Enforcement Administration chemist and an EMS medical director, and focused on the risks to fentanyl exposure and contamination to EMTs, paramedics, firefighters and police officers.

The top concern of the panelists was the availability of and proper use of personal protective equipment to protect emergency responders from exposure to fentanyl. Their top PPE recommendations were:

Immediate washing with soap and water of any exposed or contaminated skin.

Remove and clean any uniform clothing that might have been contaminated by fentanyl, blood or other potentially infectious material during patient assessment and care.

James DiSarno, senior forensic chemist, DEA, provided important historical context to the opioid epidemic. DiSarno explained that the epidemic is a result of pain management practices and flawed promotion of opioid pills as non-addictive. He recalled the growth of pain clinics for the increasing number of patients seeking pain management.

"These people were in pain," DiSarno said. "But then what happened is these people got addicted."

Those patients, now addicted to opioids, sought out illegal pills, heroin and fentanyl as the DEA put pain management clinics out of business. Drug dealers took advantage of this population of addicts by lowering the price of heroin.

"People who were never intending to use heroin turned to heroin because they were addicted," DiSarno said.

Fentanyl, because it is a synthetic, factory-made drug, is of increasing concern to the DEA and public safety leaders. Fentanyl is mostly manufactured in China and directly shipped in small qualities to buyers who find and purchase fentanyl from internet sellers.

A kilogram of fentanyl is more powerful than heroin and a tenth of the cost. One kilogram of fentanyl costs about $8,000 compared to $80,000 per kg for heroin.

Here are memorable quotes from the panelists on the opioid epidemic and protecting emergency responders from the risks of opioid exposures.

"65,000 deaths last year were attributed to drug overdoses – more than gun violence and auto accidents in a year. The opioid epidemic has impacted every community in the country. It does not discriminate."

"The risk (of fentanyl exposure) is something you have to take into consideration and you have to balance that with the likelihood that a delayed response could be fatal to the (overdosed) individual."

"A toxicologist recommended (to me) you treat these drugs like they are blood. If you see a big pile of something that looks like white powder, don't go splashing around in it."

- Dan Swayze, Public Health, PhD, MBA

Top takeaways on fentanyl dangers to emergency responders

The expert panel was convened in the wake of increasing reports of emergency responders, including police officers, paramedics, and correctional officers being sickened after assessing and treating opioid overdose patients. In addition, the panel sought to bring the best available guidance from the InterAgency Board, CDC, NIOSH and DEA on how to safely handle patients, avoid fentanyl exposure and manage a crime scene that may also be a hazmat incident.

Here are the top takeaways from the session, which will also be available for free viewing to any registered member of the PoliceOneAcademy or EMS1Academy.

1. Opioid crisis is really a fentanyl crisis

Fentanyl is cheaper and stronger than illicit opioid pills or heroin. Fentanyl derivatives and analogs come in different strengths and formulations to avoid federal regulation. DiSarno described how there are many types of fentanyl and that U4770, a fentanyl mimic, attaches to the same receptors as other opioids, but attaches more strongly.

U4990, another fentanyl mimic, came out of China a couple of months ago in response to new regulations banning U4770 production. A small change in the drug’s molecular structure makes it legal even though it has never been tested on humans.

Cushman explained that it's important to assess patients for the classic opioid toxidrome signs and symptoms of respiratory depression, reduced level of consciousness and pinpoint pupils, but because of how fentanyl is synthesized, responders might not see the classic toxidrome. The stronger binding of fentanyl derivatives to opioid receptors may require higher doses of naloxone to reverse the overdose and restore adequate respirations.

2. Assess the scene for exposure risks and crime evidence

Use dispatch information to assess the risk for fentanyl exposure through inhalation or contamination to skin or clothing. Use the scene size-up to make decisions about PPE usage and requesting additional resources.

Every overdose incident is a potential crime scene. If EMTs, paramedics and firefighters arrive before law enforcement and notice evidence of drug use or paraphernalia, they should follow local protocols to request police response.

Evidence of drugs, drug manufacturing equipment and drug administration supplies should not be touched or moved. Call local law enforcement. Moving any actual or potential evidence can compromise the investigation's chain of custody.

3. Pre-plan and train for fentanyl recognition and exposure

Because fentanyl derivatives are known to more strongly bind with opioid receptors, responders are reporting an increasing need to stock more naloxone on the ambulance and in the emergency department. Cushman also reminded attendees about the importance of BVM proficiency to ventilate any apneic patient.

The DEA is seeing fentanyl cut into every drug, including heroin and cocaine, and assumes all drug samples it is testing include fentanyl. When powdered fentanyl, as well as other drug powders, is known or suspected of being aerosolized, respiratory PPE is important since inhalation is the easiest route for accidental fentanyl exposure.

Cushman is much more concerned about fentanyl inhalation because mucousal absorption is 30 times faster than transdermal absorption. Wearing a mask is the best initial protection. DiSarno highly recommended a "dust mask" as the most important PPE and protection against aerosolized fentanyl.

5. Additional PPE for fentanyl overdose responses

In addition to a mask, the panel recommended nitrile, single-use examination gloves and safety glasses, for most responses. When there are larger amounts of hazardous material or fire risk, the InterAgency board has additional recommendations for higher levels of protection.

It's especially important to use simulation training to be proficient in opioid patient assessment and care with a mask, gloves and eye protection. Cushman encouraged attendees to practice skills like intubation and ventilation while wearing a dust mask, N100 mask or additional PPE they may be using based on the potential threat and their level of training.

6. Wash fentanyl-contaminated skin with soap and water

Responders should always wear gloves, but if they have a fentanyl skin exposure, they should first wipe the visible contamination from their skin. Next, wash skin thoroughly with soap and water, including a second water rinse.

Don't use any alcohol based sanitizers on fentanyl-contaminated skin. Alcohol increases the rate of transdermal transfer by 100 times. Use water, not an alcohol-based hand cleaner for cleaning an unknown substance off of your skin.

7. Recognize other threats, dangers

Swayze reminded attendees that IV drug users regularly engage in other high-risk behaviors. The long-term threat of hepatitis or HIV/AIDS to emergency responders has to be kept in mind because of life-changing consequences of those diseases.

Every organization has to have an exposure control plan and be committed to training personnel in how to avoid exposures, reporting exposures to blood and other potentially infectious materials, and providing testing and follow-up care when indicated by state and federal law and regulation.

Emergency responders are also at risk of compassion fatigue from the growing number of responses for opioid overdose, especially for patients who have overdosed multiple times. Recognizing the potential for compassion fatigue, which leads to burnout, and providing training on the science of addiction is important for every public safety organization.

Media-hyped accounts of police officers or paramedics who are alleged to have been overcome by fentanyl after caring for a patient might be causing responders to worry about their own safety. Education about potential routes of exposure, enforcing policies and procedures, making PPE available and distributing medical intelligence about the opioid epidemic are all important to giving responders peace of mind while performing their lifesaving duties.

Final recommendations

Chris Cebollero, Inside EMS podcast host and event moderator, asked each of the panelists for their final recommendations to EMTs, paramedics, firefighters and police officers.

"We are not going to arrest or seize our way out of this. We have to start with youth and have conversations at an early age to talk about the issues and cycle (of addiction). Safety and prevention is really the key."

"Illicit tablet makers have gotten so good, the DEA labs can't visually tell the difference between a fake oxycodone tablet and a real tablet. Fake tablets are being produced by hundreds of thousands per day."

"Download the 14-page (InterAgency Board) document. It will guide you through the policies and training, which we cross walked with NIOSH and DEA procedures for personal protection. Be smart, be clinical, be professional – we'll get through this."

"Take care of yourselves and colleagues. We can't tackle this issue just by administering more and more Narcan. Reach out to drug and alcohol addiction folks, police brothers and sisters to work together to reduce supply and reduce demand."

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EMS1 is revolutionizing the way in which the EMS community finds relevant news, identifies important training information, interacts with each other and researches product purchases and suppliers. It has become the most comprehensive and trusted online destination for prehospital and emergency medical services.

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